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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004489
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:27:11 PM

Document Has Been Signed on 11/30/2023 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WENDY & PETER CARE HOMEFACILITY NUMBER:
306004489
ADMINISTRATOR:LINDA PHUONG LINH TRANFACILITY TYPE:
735
ADDRESS:273 23RD STREETTELEPHONE:
(949) 645-8697
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 5DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Rosanna Magkawas - Direct Care StaffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry by Direct Care Staff (DCS) Rosanna Magkawas

The facility is a one-story home with three resident bedrooms, two bathrooms, kitchen, dining room, living room, staff room, back yard and attached two-car garage. LPA observed facility to be clean, sanitary and in good repair. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restroom hot water measured at 111.9 degrees Fahrenheit in the bathroom closest to the client rooms and 114 degrees Fahrenheit in the bathroom closest to the staff room. LPA observed board games, exercise equipment and books for resident use. Facility has one shaded seating area in the backyard. Smoke and Carbon Monoxide detectors tested operational. LPA observed facility has emergency food and water supply in the front closet. Appliances are operational. Facility has a 2-day supply of perishable food and a 7-day supply of non-perishable food. Fire Extinguisher was observed to be fully charged as indicated by the built-in meter. LPA observed facility has a storage shed in the backyard. The shed remains locked and appears to only be used for miscellaneous storage. LPA observed client medication and staff files to be locked in a cabinet in the living room. LPA reviewed medication for three clients and all of the clients' files. Medication appeared to be properly administered and documented. LPA also reviewed P&I with DCS. Client money and expenses appear to be properly stored and documented. LPA reviewed three staff files.

Based on today’s inspection, no deficiencies were cited.. An exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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